Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
George Hospital
These protocols are only intended to provide general guidelines for the dietary
management of patients with Renal Failure. Each patient will receive an
individualised diet prescription and education by the dietitian.
Contents Page
D. Abbreviations used. 5
1. Hypertension (general) 6
5. Nephrotic Syndrome 10
7. Haemodialysis (HD) 13
F. References 22
2
A. Common Nutritional Goals For Renal Disease Management:
To attain and maintain ideal body weight (IBW) and lean body mass (LBM).
Control of hypertension.
Control of hyperphosphataemia.
3
B. Guidelines and Policy for Referrals (both inpatient and outpatients)
2. Blanket Referral:
- CKD clinic
- Dialysis – Haemodialysis and Peritoneal Dialysis (CAPD, APD
and IPD)
- Transplantation.
4
C. Guidelines and Policy of Nutrition Related Issues
Medication Used
- Phosphate binders:
D. Abbreviations Used
5
E. Nutrition Management Protocols
1. Hypertension (General)
Remarks: The guidelines below are applicable to people with or without renal
impairment. However, dietary prescription must be adjusted
according to the individual's conditions, e.g. hyperkalaemia,
hyperphosphataemia, diabetes etc.
______________________________________________________________________
Dietary Protocol:
Increased Fruit, vegetables and low fat dairy products for increased intake
Consumption of: of potassium, magnesium, calcium and fibre.
Moderate
Consumption of: Protein
Decreased
Consumption of: Saturated fat, total fat and cholesterol.
6
2. Early Renal Failure
Description:
Stage 1-2 CKD
Asymptomatic
Dietary Protocol:
- Cholesterol <300mg/d
- Saturated fat <10% of energy.
7
3. Moderate Renal Failure
Description:
Stage 3 CKD
Dietary Protocol:
Vitamins &
Minerals
(supplementation): May need individualised Calcium, Iron and Vitamin D
supplementation. May need supplementation of Vitamin B
complex, Vitamin C and folate acid near RDI levels if protein intake
is <60g/day.
8
4. Advanced Renal Failure (Pre-Dialysis)
Description:
Stage 4-5 CKD
Symptomatic
Referral: Medical Officer referral required or from “Blanket referral of the CKD
clinic)
___________________________________________________________________
Dietary Protocol:
Vitamins &
Minerals
(supplementation): Individualized Calcium, Iron and Vitamin D.May need
supplementation of Vitamin B complex, Vitamin C
and folate acid if protein intake is <60g/day.
9
5. Nephrotic Syndrome
1. Control of proteinuria.
2. Control of fluid balance.
3. Control of lipid abnormalities.
___________________________________________________________________
Dietary Protocol:
10
6. Acute Renal Failure
Dietary Protocol:
Sodium: Individualised
Anuric or oliguric phase, 60-80mmol/d
Polyuric phase, no restriction or higher intake to replace urinary
losses.
Potassium: Individualised
If hyperkalaemia present, 40-70mmol/d
Polyuric phase – may need high K+ diet.
Vitamins &
Minerals: As per advanced CRF and Haemodialysis protocols (4 & 7).
11
Calculation of daily energy requirements in ARF:
ACTIVITY
INJURY FACTOR
FACTOR
12
7. Haemodialysis (Stage 5 CKD)
Dietary Protocol:
To aim:
- nPCR ~1.1-1.2g/kg IBW/d
- URR 65%
- pre-dialysis urea ~ 25 mmol/l
Higher requirements for malnourished patient (~1.5g/kg IBW/d)
Approximately 60-70% HBV protein.
Vitamins & Vitamin B complex and Vitamin C and folic acid near the RDI
Minerals: levels. Individualised Vitamin D, Iron and Calcium supplement
(supplementation):
13
8. Peritoneal Dialysis (Stage 5) :Continuous Ambulatory Peritoneal Dialysis
(CAPD)
Dietary Protocol:
Vitamins & Vitamin B complex and Vitamin C and folic acid near the RDI
Minerals: levels. Individualised Vitamin D, Iron and Calcium supplement
(supplementation):
14
9. Peritoneal Dialysis (Stage 5): Automated Peritoneal Dialysis (APD)
also known as Continuous Cyclic Peritoneal Dialysis (CCPD)
As per CAPD.
___________________________________________________________________
Dietary Protocol:
Protein:
Energy:
Sodium:
Potassium: *
Lipids:
Vitamins &
Minerals:
Fluid:
15
10. Peritoneal Dialysis (Stage 5): Intermittent Peritoneal Dialysis (IPD)
As per CAPD
Remark: – this procedure has rarely been performed in SGH over last few years. It
is usually used in patients needing respite care and attending hospital PD.
– The literature has suggested different diets for dialysis and inter-dialysis
days.* However, to minimise confusion to patients, the following diet
prescription will be implemented for all days.
______________________________________________________________________
Phosphorus: <1200mg/d.
Vitamins &
Minerals: As for CAPD.
16
11. Renal Transplant
Pre-transplant diet (see haemodialysis or CAPD protocol) and protein and energy
requirement as below until graft functions.
17
12. Metabolic Disorders (Renal Related)
2. Fluid: High and regular fluid intake, about 2.0-3.0 L/d, preferably WATER, to
produce at least 2 litres urine per day. Regular intake throughout the day, say
second hourly. If suggested by the MO, drink enough fluid at bed-time to aim for
nocturia, and to consume extra fluid after voiding.
___________________________________________________________________
1. Hypercalciuria:
2. Hyperoxaluria:
Protein:
Sodium: As per hypercalciuria
Fibre:
18
3. Hyperuricosuria:
4. Cystinuria
19
13. Nutritional Support
2. If oral nutrition supplementation fails, liaise with AMO re indication for enteral
feeding.
20
14. Renal Diagnostic Test Diets
TEST DIET
21
References
General References
Hypertension
Pre-Dialysis CRF
22
Nephrotic Syndrome
2. Monson, P and Mehta RL. Nutrition in ARF - A reappraisal from the 1990s. J. Renal
Nutrition 1994;4(2):58-77.
Haemodialysis
CAPD
Transplantation
1. Chazot, C. & Kopple JD, Vitamin Metabolism and requirements in Renal Disease and
Renal Failure, Kopple JD & Massry SG, Nutritional Management of Renal Disease,
Williams & Wilkins 1997, Chapter 15 & 16.
2. Makoff R. Water Soluble Vitamin Status in patients with renal disease treated with
haemodialysis or peritoneal dialysis. J. Renal Nutrition 1992;1(2):56-73.
Nutritional Support
1. Faulks, C.J. Intradialytic Parenteral Nutrition, Kopple JD & Massry SG, Nutritional
Management of Renal Disease, Williams & Wilkins 1997, Chapter 20.
2. Treatment of malnutrition with 1.1% amino acid peritoneal dialysis solution AKJD Vol.
32, No.5 (Nov) 1998 p761-769.
Metabolic Disorders
1. Massey L.K., Roman-Smith, H and R.L. Sutton. Effect of dietary oxalate and calcium
on urinary oxalate and risk of formation of calcium oxalate kidney stones. J. of
American Dietetic Association.
23